One reason why the emotional component of mania may have been so badly misunderstood is that it is usually not an immediate source of concern to other people. More often it is non-mood symptoms that draw attention to the patient and precipitate an admission to hospital.
Stage I
Stage II
Stage III
Mood
Lability of affect; euphoria predominates; irritability if demands not satisfied
Increased dysphoria and depression, open hostility and anger
Clearly dysphoric; panic-stricken; hopeless
Cognition
Expansivity, grandiosity, overconfidence; thoughts coherent but occasionally tangential; sexual and religious preoccupation; racing thoughts
Flight of ideas; disorganization of cognitive state; delusions
Incoherent, definite loosening of associations; bizarre and idiosyncratic delusions; hallucinations in 1/3 of patients; disorientation to time and place; occasoinal ideas of reference
Behavior
Increased psychomotor activity; increased initiation and rate of speech; increased spending, smoking, telephone use
Continued increased psychomotor acceleration; increased pressured speech; occasional assaultive behavior
Frenzied and frequently bizarre psychomotor activity
Adapted from Carlson and Goodwin, 1973
Figure 11.1 The three stages of mania described by Carlson and Goodwin (1973), reproduced from F. K. Goodwin and K. Jamison (1990), Manic-Depressive Illness, Oxford, Oxford University Press.
The reckless activity that is common in manic episodes can provoke alarm in friends and relatives, causing them to seek the advice of doctors and psychiatrists. One of my patients drove his car at frightening speeds down country lanes, convinced that he was invincible. The car rolled on a corner and was damaged beyond repair but my patient walked away from the accident unscathed, his conviction in his own indestructibility reinforced by the experience. Not surprisingly, his more realistic parents ensured he had an early appointment at a local psychiatric clinic.
Fortunately, life-threatening deeds of this sort are fairly unusual. It is also rare for patients to act on their heightened sexual feelings (experienced by 57 per cent of patients according to Goodwin and Jamison). When they do, they more often expose themselves (29 per cent) than make sexual advances towards other people. (A young man whom I was interviewing for the first time disclosed that, during a recent episode, he had run around a hospital ward wearing just one sock, adding, ‘And it wasn’t on my foot!’) More mundane activities that are characteristic of mania or hypomania include excessive use of the telephone (recovered patients often find that they have enormous phone bills) and extravagant spending that is regretted later (Kay Jamison once bought a large number of Penguin books, because she thought that they would like to live together in a family).
Goodwin and Jamison’s review of psychotic symptoms in manic patients reminds us that bipolar symptoms overlap with those that are normally attributed to schizophrenia. They estimate that about 15 per cent of patients experience hallucinations, which are usually in the auditory modality. Abnormal beliefs are more common, with grandiose delusions reported by 47 per cent of patients and paranoid delusions reported by 28 per cent. Language and communication problems are also frequently observed. Although most psychiatrists, following the example set by Bleuler, have regarded incoherent speech as a symptom of schizophrenia, Nancy Andreasen discovered that it is more often evident in patients with a diagnosis of bipolar disorder,10 an observation that has been confirmed by other researchers.
From this evidence, it is obvious that mania, like depression, is not a symptom, but a complex group of symptoms (some of which are discussed in other chapters of this book). Unfortunately, the very limited psychological research that has so far been carried out with bipolar patients (including my own) has tended to treat mania as a lump, so it is not always clear which characteristics of manic episodes are associated with the processes that have been investigated.
An insight from psychoanalysis?
The earliest systematic contributions to the psychology of mania were made by psychoanalysts. Of those who studied the problem, the most important was Karl Abraham. Born in Bremen in 1877, Abraham became Bleuler’s assistant at the Burghölzli Hospital in Zurich, where he fell under the influence of the Freudians, despite developing a strong dislike for Jung. Until his premature death from cancer in 1925, he was one of Freud’s most loyal disciples. He was described by Freud’s biographer Ernest Jones as, ‘Certainly the most normal of the group. His distinguishing attributes were steadfastness, common sense, shrewdness, and a perfect self-control.’ However, Jones qualified this observation by adding, ‘One would scarcely use the term “charm” in describing him; in fact, Freud sometimes told me he found him “too Prussian”.’11
In a paper published in 1911, Abraham argued that:
Viewed externally, the manic phase of the cyclical disturbances is the complete opposite of the depressive one. A manic appears very cheerful on the surface; and unless a deeper investigation is carried out by psychoanalytic methods it might appear that the two phases are the opposite of each other even as regards their content. Psychoanalysis shows, however, that both phases are dominated by the same complexes, and that it is only the patient’s attitudes to these complexes that is different. In the depressive state he allows himself to be weighed down by his complex, and sees no other way out of his misery but death; in the manic state he treats the complex with indifference.12
Abraham’s proposal was that the underlying psychological processes in mania are similar to those in depression, but that, in the manic state, these processes are experienced as intolerable and are therefore denied. This idea was later elaborated by Sandor Rado, the Hungarian-born psychoanalyst whose ideas about anhedonia we considered earlier. Rado argued that manic-depressive patients are highly narcissistic, and that the manic defence is therefore motivated by an abnormal need for approval by others.13
The manic-defence hypothesis has been neglected by psychological researchers, mainly because of persisting doubts about the scientific status of psychoanalysis. Because the early psychoanalysts were unable to frame their theories in ways that could be tested experimentally, and even refused to recognize the value of the experimental method, many modern psychologists have assumed that their ideas were not worth investigating.14 In doing so, they have forgotten that the early psychoanalysts made perceptive observations about the behaviour of their patients, and have failed to recognize that many of their theories seem less bizarre when translated into ordinary language. This is certainly true of the idea of defence, which simply implies that we attempt to regulate our own emotions by avoiding thoughts that are exceptionally distressing. Evidence in support of this idea is not difficult too find, and we have already encountered some of it in the previous chapter.
In fact, there has been at least one attempt to restate the manic-defence hypothesis in the language of modern psychology. John Neale, working at the State University of New York in the late 1980s, suggested that people who are vulnerable to manic episodes suffer from unrealistic standards for success and unstable self-esteem. According to Neale’s account, when negative events intensify the vulnerable person’s underlying feelings of low self-regard, he responds with a cascade of grandiose ideas, which inhibit distressing thoughts about the self. These grandiose ideas in turn rapidly spiral out of control, causing mood elevation and eventually mania.15
Is There a Manic Defence?
Because so few data were available to him, Neale’s reformulation of the manic-defence hypothesis was necessarily vague. In fact, the hypothesis can be expressed in various forms. A weak version implies that mania is triggered by incipient negative mood, or perhaps the threat of negative mood, and reflects patients’ efforts to avoid negative emotion. A stronger version would also imply that the manic state consists of an underlying depression that is somehow masked by these efforts
. (An ultra-strong version, consistent with the claims of psychoanalysis, would go still further, and suggest that these symptoms enable patients to avoid awareness of their underlying depression altogether. However, because of the considerable difficulties in establishing what patients are really aware of – as opposed to just ignoring – I will leave this issue to cleverer minds than mine.)
The remitted bipolar patient
If episodes of mania are triggered by incipient negative mood, it follows that remitted bipolar patients should have many of the psychological characteristics of depressed patients, and that the more they have these characteristics, the more likely it is that they will become manic. At least one piece of evidence seems, at first sight, inconsistent with these assumptions. When patients are asked to recall their experiences of the prodromal phase of the disorder, they usually report symptoms of excitement (for example, reduced sleep, increased activity, excessive talkativeness, euphoria and racing thoughts) rather than symptoms of depression.16 However, this evidence is far from conclusive. As we have seen, patients often have difficulty recalling their symptoms, and, in any case, we probably need to look further backwards in time than the prodrome, which marks the beginning of the manic state.
Although it has often been assumed that remitted patients suffer from no symptoms of any importance, and function just as well as ordinary people, recent studies suggest that this impression has arisen simply because they usually live their lives beyond the sight of psychiatrists and clinical psychologists. ‘Subclinical’ depression, it seems, is the norm.17 Remitted bipolar patients also appear to have many of the psychological characteristics of depressed patients, even if they are sometimes reluctant to reveal them. One of the earliest investigations to demonstrate this was conducted by Ken Winters and John Neale, who argued that, because patients would respond defensively, it would be misleading to study the psychology of the remitted state using conventional questionnaires.18 They therefore devised a non-obvious or implicit test of attributional style, known as the Pragmatic Inference Task (PIT), which is disguised as a memory test. People taking the test are asked to listen to a series of brief stories such as the following:
You decide to open your own dry-cleaning shop in a small but growing town near the border. Your shop will be the only one of its kind for miles around. In the first year of business, the town’s population doubles and your business prospers. Your advertising campaign is a big success and reactions from your customers indicate that the cleaning is of good quality. Your gross sales exceed expectations. You wonder whether it would be to your advantage to open a chain of shops, so you go to the bank and apply for a loan. As you had hoped, the bank approves the loan.
After each story, the participant is asked to answer a number of multiple-choice questions, some of which have clear right and wrong answers. (For example: What kind of shop did you open? A: Hardware or B: Dry-cleaning. The answer, obviously, is B.) However, one question after each story asks listeners to recall which of two causes (one internal and one external) was responsible for the good or bad outcome portrayed (What is the reason for the success of your business? A: You are a clever businessman or B: You have no competition). The stories are carefully constructed so that neither answer is more obviously correct than the other. Therefore, Winters and Neale argued, the answers chosen will reflect the way that participants feel about themselves. Winters and Neale found that, like unipolar depressed patients but unlike ordinary people, remitted bipolar patients made internal (self-blaming) attributions for negative events much more than for positive events.
Winters and Neale also measured a characteristic known as social desirability.19 This slightly confusing term refers to the need to present a positive image of the self to others. Questionnaires that measure social desirability invite people to admit to undesirable but common dispositions and behaviours (for example, gossiping about others, playing sick to gain advantage). It is assumed that people who deny these characteristics are so defensive that they are unable to admit to even trivial shortcomings. Winters and Neale found that their remitted bipolar patients scored much higher on this measure than ordinary people.
This study, published in 1985, was largely ignored by other investigators. In the past few years, however, researchers have used other measures to confirm Winters and Neale’s general observation of depressive processes in remitted patients. For example, Jan Scott and her colleagues in Newcastle recently administered the Dysfunctional Attitudes Scale (the measure of perfectionist self-standards that I briefly described in the last chapter) and found that remitted patients, like people suffering from depression, scored much more highly than ordinary people.20
My earliest research with bipolar patients attempted to detect underlying depressive processes in people who were vulnerable to bipolar symptoms, and made use of an obscure psychological phenomenon known as the Stroop effect. In 1935, a British psychologist, J. R. Stroop, reported an experiment in which ordinary people were asked to look at a series of colour words printed in incongruent ink colours (for example, the word ‘red’ might be printed in blue, the word ‘green’ might be printed in red, and so on). The people taking part in the experiment were asked to name the ink colour of each word but to ignore the word itself. Stroop observed that people find this task very difficult – the participants in his experiment were much slower at this kind of colour-naming than when colour-naming words in congruent ink colours (for example, ‘green’ printed in green) or meaningless strings of letters (for example, ‘XXXXX’) written in different ink colours.21 The precise mechanisms responsible for this effect are still debated. However, it is safe to assume that people find it hard to suppress the habit of reading the word itself, creating an internal competition between reading and colour-naming. To anyone attempting the task, this urge to do two things at once creates the weird subjective sensation that the mind is filling with glue.
The Stroop effect is useful to clinical psychologists, because it occurs for any words that draw the individual’s attention. This is especially the case for words that have some kind of emotional significance and which reflect a source of worry. Depressed patients but not ordinary people are much slower to colour-name depression-related words (for example, ‘failure’, ‘sadness’) than emotionally neutral words (‘diamond’, ‘collector’).22 Similarly, anorexic patients are slow to colour-name food words23 and anxious patients are slow to colour-name anxiety-related words.24
Michelle Thompson and I used the Stroop technique to test university students whom we selected according to their scores on a hypo-mania questionnaire. We gave the students a Stroop task with depression-related words (for example, ‘dread’, ‘rejected’), euphoria-related words (‘wonderful’, ‘glorious’) and emotionally neutral words (‘pod’, ‘tendency’). As predicted, the hypomanic students showed slowed colour-naming for the depression-related but not for the euphoria-related words, suggesting that the former words were emotionally troubling to them.25 Although this finding might seem to be slightly counter-intuitive – after all, the hypomanic students did not show any evidence of depression – it has since been replicated by Chris French at the University of London, who started out by questioning some aspects of our methodology, but who ended up obtaining almost identical findings when using his own methods.26
In two more recent studies, conducted in Manchester with my students Julie High field and Tom Woodnut, we decided to investigate self-esteem in well-adjusted students with hypomanic personality traits, and also in a group of remitted bipolar patients.27 Aware of the evidence that self-esteem is often highly unstable in people who are vulnerable to depression, we decided to measure it daily in both groups and matched controls, using the diary method devised by Michael Kernis.28 Participants completed a very simple self-esteem questionnaire and also answered a series of questions twice a day for a week about what had been happening to them. We compared each of the target groups – the hypomanic students and the remitted patients – to control groups mat
ched with them for age, sex and educational achievement and found that the self-esteem scores of both the hypo-manic students and the remitted patients fluctuated more markedly than the scores of these comparison groups. Interestingly, although neither the hypomanic students nor the remitted patients scored very highly on a measure of depression, their scores exceeded those of their respective controls, and when we allowed for this difference statistically, the differences in stability of self-esteem were no longer evident. The unstable self-esteem of these groups therefore seemed to reflect ‘bubbling’ subclinical depression.
The manic-defence hypothesis suggests not only that individuals vulnerable to mania should experience incipient depressive symptoms, but also that the severity of their depressive psychological processes will predict the likelihood that they will become manic in the future. As yet, only one study has properly addressed this prediction. Lauren Alloy and her colleagues tried to extend the high-risk research strategy they have developed for the study of depression to bipolar symptomatology. They used a questionnaire followed by a psychiatric interview to screen 3000 students for a history of mood symptoms. This led them to identify 49 apparently bipolar students, most of whom were well when first assessed, and a group of 97 students with an apparent history of unipolar depression, most of whom were also well. After being tested on a range of psychological measures, including attributional style, these groups, together with a small control group, were reassessed one month later. Unfortunately, because of the small numbers in the study, the researchers did not report separate attributional style data for currently depressed and currently manic participants. However, in both the bipolar and unipolar group, there was evidence that a pessimistic attributional style predicted an increase in depressive symptoms at the follow-up assessment. More interestingly, in the bipolar group, a pessimistic style also predicted an increase in manic symptoms.29
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